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Affidavit Of Relinquishment Counseling JDF 453 - Colorado
|Affidavit Of Relinquishment Counseling Form. This is a Colorado form and can be used in Adoption Statewide .||
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! District Court ! Denver Juvenile Court __________________________________________County, Colorado Court Address: IN THE MATTER OF THE PETITION OF: And Petitioner(s) FOR THE RELINQUISHMENT OF A CHILD, COURT USE ONLY (child's name) Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: FAX Number: E-mail: Atty. Reg.#: Division AFFIDAVIT OF RELINQUISHMENT COUNSELING ________ of / Child Placement Agency, state that I Courtroom I, County Department of Social _______ provided counseling to Services on the following dates concerning Petitioner's Petition for Relinquishment filed in this action. 1. The nature and extent of counseling included the following: ! ! ! ! ! ! ! Information to Petitioner concerning the permanence of the decision to relinquish and the impact of the decision on Petitioner now and in the future. Information was obtained from Petitioner about the complete medical and social histories of both of the child's parents. If Petitioner was pregnant, Petitioner was referred for medical care and a determination of eligibility for medical assistance. Information about alternatives to relinquishment and a referral to private and public resources that may meet the parents' needs. Information about relinquishment services necessary to protect the interests and welfare of the child if the child was born in a state institution. Information that if Petitioner applies for public assistance for Petitioner or the child, Petitioner must cooperate with the Child Support Enforcement Unit for the establishment of a child support order. That all information, except non-identifying information as defined in Section 19-1-103(80), C.R.S., obtained in the course of relinquishment counseling, is confidential, unless the parent provides written information or a court orders a release of information. Other counseling provided: ! 2. The Affiant has prepared a report as "Exhibit A" that outlines the process of relinquishment counseling in more detail. DATE: Counselor JDF 453 R4/00 AFFIDAVIT OF RELINQUISHMENT COUNSELING 1 2000 © American LegalNet, Inc. STATE OF COLORADO COUNTY OF _________________________________________ The Affiant, being first duly sworn on oath, deposes and states that he/she has read the foregoing Affidavit of Relinquishment Counseling and knows the contents thereof and that the information contained therein is true and accurate to the best of his/her knowledge and belief. DATE: Counselor Subscribed and sworn to before me this ______ day of ________________________________________________, __________. My Commission expires:______________________________ ____________________________________________ Clerk/Notary Public JDF 453 R4/00 AFFIDAVIT OF RELINQUISHMENT COUNSELING 2 2000 © American LegalNet, Inc.